CM programs can vary in terms of how the incentive is structured and can use incentives in the form of vouchers, prizes, or cash. The vouchers have monetary value and can accumulate in a clinic-managed account as the patient remains substance-free. Instead of providing money directly to patients, program or clinic staff can use the earned amount in vouchers to purchase items requested by the patient that are reasonable and consistent with positive lifestyle change . Typically, patients purchase clothing, electronic equipment, sporting/hobby items, and recreational items with their vouchers. Items can also be stored in a space that CM studies refer to as a “prize cabinet” . The prize cabinet provides patients the opportunity to identify tangible prizes that may motivate them to continue treatment. The prize cabinet can consist of items ranging in value, from jumbo value to large or medium prizes to small prizes . Typically, patients in incentive programs earn at least one voucher for each urine sample that tests negative for the target substance. The structure of the incentive typically escalates, with each subsequent behavior being rewarded at a higher value than the previous one, thus incentivizing longer-term abstinence.Provider supply including provider attitudes and geographic access can pose structural barriers to SUD treatment. Lack of available providers to treat SUDs in a specific geographic region, and more specifically a lack of providers who have been trained to administer CM as part of SUD treatment, will limit the extent to which patients can access treatment. Patients may also face supply issues or geographical and transportation barriers to accessing SUD treatment using CM . A provider office would need to have the ability to monitor abstinence through urinalysis as well as the administrative capacity to administer the program. Provider willingness to treat SUDs using CM can also be limited; not all providers are comfortable offering CM programs due to a lack of training, lack of office space and support resources, cost, time pressure, or personal beliefs against using incentives to treat SUDs .
Technological advancements in the field, such as webbased contingency management or smartphone technology, are addressing administrative barriers, including staffing and training,cannabis indoor grow system and have shown to increase patient compliance . For many patients with SUDs, attitudinal barriers are the most significant barrier to treatment initiation and persistence . The stigma of SUD and the ability to acknowledge having an SUD can affect patient desire to seek care even more so for those who have co-occurring psychiatric conditions.Rapp et al. tested a Barrier to Treatment Inventory tool to assess perceived barriers to treatment for those with SUDs. They reported significant correlation among six of the seven barrier factors: absence of a problem; negative social support; fear of treatment; privacy concerns; time conflict; poor treatment availability; and admission difficulty. Another barrier for patients participating in treatment specifically using CM is the requirement to travel to the provider’s office, sometimes up to two or three times a week. This can cause more of a burden for patients who do not have flexible schedules and those who are living in areas with a shortage of providers who treat SUDs and a lack of access to providers that are administering CM programs . However, when CM is administered as an adjunctive component of psychosocial treatments in the context of intensive outpatient programs , patients are already traveling to attend therapy, where they will also submit their urine samples, the required two to three times per week.Taken as a whole, treatment of SUDs is inextricably linked bi-directionally with many important SDoH. SDoH such as quality of a person’s local built environment, proximity to crime, educational opportunities, self-efficacy, and income levels can influence a person’s risk for SUDs . Conversely, SUDs can also alter a person’s baseline SDoH namely through the consequences of SUD, such as involvement with the criminal justice system, job loss, unstable housing or family situations, and discrimination against those with treated or untreated SUDs . Disparities for SUDs exist by gender, age, race, sexual orientation. Males tend to have higher rates of substance use disorders than females . Young adults tend to have the highest prevalence of all SUDs, with most rates peaking in the 20s across gender and racial groups .
Although whites tend to have a higher prevalence of most SUDs in young adulthood, Blacks tend to have a higher prevalence in later life . In addition, Blacks, Native Americans, and Mixed-Race adults have a higher prevalence of cannabis use disorder, regardless of age . Further, lesbian, gay, and bisexual individuals are more likely to have SUDs, oftentimes more severe, than heterosexuals . Another risk factor for SUD is related to mental illness. More than half of people with serious mental illness also have an SUD, a combination which is referred to as dual diagnosis . Patients with SMI have a particularly difficult time with addiction because substances are often used as a coping mechanism for mental health symptoms . Treating SUDs is very important because individuals with dual diagnosis are at higher risk of hospitalizations, suicide, premature death, and criminal justice issues than individuals with SMI but no SUD . There is not one standard way to conduct CM for SUDs. This means that there are a range of ways to structure the reward offered for different targeted behaviors across SUDs. The CM program can vary in terms of the duration, incentive value, and format . This lack of uniformity leads to difficulty in combining results across studies. In addition, although each substance is reviewed separately in this report, poly-substance use is common among those diagnosed with SUD, and many patients have more than one SUD. The diagnosis and treatment of multiple SUDs is complex and treatment and recovery rates for each SUD may vary for a single patient. It is possible for a patient to be in recovery from one SUD but not another. While some of the studies included in this review targeted multiple substances, CHBRP did not review each possible combination of substances separately to assess the impact of CM but rather focused on targeted outcomes for the two substances identified as relevant for this bill, stimulants and cannabis, both within the context of poly-substance use and as singular substances of misuse.Studies of CM for cannabis and stimulant use disorder have primarily examined outcomes related to abstinence, treatment adherence, and treatment retention/attrition. All the reviewed studies reported abstinence from targeted drugs as a primary outcome. For these studies, abstinence was measured as the longest duration of continued abstinence or as the number or percentage of negative samples tested during the study period. For studies in which treatment retention and/or treatment adherence were primary outcomes, retention was defined as the number of weeks in treatment , and adherence was defined as the number or percentage of scheduled appointments attended in a given time period. Secondary outcomes examined included health care utilization including emergency room visits and hospitalizations. For all of these studies, outcomes were reported during treatment, at the conclusion of treatment, and/or up to 12 months post treatment. None of the studies reported follow-up evaluations past a 12-month follow-up.
This following section summarizes CHBRP’s findings regarding the strength of evidence for the effectiveness of CM for SUDs. It begins with a broad overview description and evaluation of CM for SUDs and then focuses on the literature specific to stimulant and cannabis use disorder alone and in the context of poly-substance use disorder. It also describes the literature on CM for special populations, including pregnant women and persons with dual diagnoses, defined as having been diagnosed with both severe mental illness and SUD, due to this population’s unique struggles and susceptibility to SUDs. Some studies compared CM alone to treatment as usual while others compared CM as an adjunctive component of other psychosocial programs that are commonly used to treat SUDs . In these cases, CM was used for the duration of treatment and ended at the conclusion of the treatment period. Each section is accompanied by a corresponding figure. The title of the figure indicates the test, cannabis equipment treatment, or service for which evidence is summarized. The statement in the box above the figure presents CHBRP’s conclusion regarding the strength of evidence about the effect of a particular test, treatment, or service based on a specific relevant outcome and the number of studies on which CHBRP’s conclusion is based. Definitions of CHBRP’s grading scale terms is included in the box below, and more information is included in Appendix B.Although individuals with SUDs are typically treated in the same SUD treatment programs together and often use or abuse more than one substance, studies examining the efficacy and effectiveness of CM typically focus on each substance individually given the variable patterns of use across substances. Therefore, the majority of the analyses conducted and conclusions drawn below are broken down by substance. Research on other relevant variables such as vulnerable populations are also worthy of consideration and have been summarized in systematic reviews. Biochemical verification of abstinence is common across all SUDs and is a standard component of most treatment programs. It is nearly universally present in CM programs given that reinforcements are typically made based on biochemically verified abstinence . However, substances are verified by different types of specimen collection. Urinalysis is most commonly used as a verification method for stimulants and cannabis . Metabolites for stimulants in urine are typically detected for a time period of 48-72 hours, which aligns well with the typical time period between screens in treatment programs. Biochemical verification for cannabis presents challenges in terms of the amount of time it can be detected after use, which is highly dependent upon frequency and amount of use. Nevertheless, urinalysis is commonly used as a detection method for cannabis in treatment programs with modifications in terms of frequency and timing to account for potential longerterm storage in bodily tissue. Other types of biochemical verification, such as saliva, breath, and blood, are more common in other substances .This review identified four systematic reviews that examined the structure of the CM program on outcomes. Davis et al. reviewed 69 studies of voucher-based CM programs enrolling a total of 2,675 people. Eighty-six percent of these studies reported positive treatment effects, with an overall standardized mean difference between CM and usual care groups of d = 0.62 .
Lussier et al. also conducted a meta-analysis of 30 studies of voucher-based CM programs and found that greater effects were seen for immediate rewards compared to delayed rewards. They also found that the abstinence effect size was proportional to the size of the reward . Benishek et al. reviewed 19 studies enrolling 2,581 participants in prize-based CM studies. They found that prizebased CM was effective in increasing abstinence during treatment with an average treatment effect size of d = 0.46 . In another systematic review focused primarily on abstinence, Prendergast et al., found that among the 47 studies it reviewed, the three most frequently used types of CM were vouchers , take home methadone doses , and cash . The value of the rewards given in CM programs varies considerably in the literature. Although the amount that patients receive for the earliest negative samples are often relatively low , escalating values based on continuous abstinence enables them to receive rewards of higher value in relatively short periods of time. Maximum single rewards range from as little as $0.45 to as much as $25.89 , with maximal total earnings ranging from $180 to $1,155 over a 12-week period . In a review of studies, the average total available to earn over 12 weeks was $914.46 . Other studies that have extended longer than 12 weeks and/or used other types of reinforcement models have offered reward values up to $3,201 across 24 weeks, $2,294 in living expenses over 12 weeks, and $5,800 worth of take-home methadone doses over 52 weeks . One RCT examined the relative effect of the total value of rewards on abstinence and attendance among individuals with stimulant use disorder in a methadone patient population. They found that patients offered larger prizes whose value maxed out at $560 achieved longer durations of abstinence than those offered prizes whose value maxed out at $250.